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Hypothesis: The Research Page


Measuring psychological stress
Concept, model, and measurement instrument in primary care research
Louise Lemyre, PHD Rjean Tessier, PHD

irst introduced by Selye, the term stress is now


widely used to describe a state of tension often
seen as being related to modern life. In the context
of primary care, a definition integrated into a conceptual model with a validated measurement instrument
would help to ensure that this term is used appropriately. This article is designed to provide primary
care researchers with a concept, a model, and a psychological stress measurement tool adapted to their
context and needs.

Concept of stress

Psychological stress concerns the state of normal


tension, preoccupation, and agitation reported by
many people. Sometimes extreme and sometimes
an energy booster, its statistical distribution is normal, and it is considered a precipitating factor in the
development of various physical and mental disorders. It is, however, different from distress and psychopathology, which are dysfunctional and morbid.
All too often, researchers and clinicians use
clinical psychiatric measurement tools (such as
the Present State Examination, the Brief Symptom
Inventor y, or the Beck Depression Inventor y) to
assess stress. These were designed for pathologic
disorders and validated using dysfunctional clinical
populations. Their statistical distributions are not
normal, and they are not particularly sensitive below
the critical diagnostic threshold. In contrast, the concept of stress refers to a set of affective, cognitive,
somatic, and behavioural manifestations within the
range of functional integrity.

Stress model

The general theoretic framework we developed is


based on a biopsychosocial model of stress that
includes environmental parameters and individual
processes of perception and coping with stressors.

Developed outside the field of psychopathology, this


model is ideal for assessing psychological stress in
primary care and population health research. The
state of stress depends on the interaction between
an individuals environment and his or her representation of that environment. It can result in physical
or mental illness through the agency of neuro-endoimmune mediators and depending on various structural or functional vulnerabilities. Stress disorders
occur only as a result of stress of great intensity or
long duration or when other pathogenic processes
are present. Psychological stress is, therefore, a
hinge construct associated with both psychological
phenomena and factual parameters.

Measuring psychological stress

In our qualitative studies, stress was recognized


as a target construct in the process of adapting to
life events and circumstances; it appeared socially
acceptable. For this reason, it warranted a measurement instrument validated for the specific concept of
stress that is reliable, responsive, user-friendly, and
economical.
The Psychological Stress Measure (PSM) was
designed using 49 items drawn from descriptors
generated by focus groups on stress.1 For content
validity, we conducted a quantitative analysis of items
selected as the best indicators of stress. We then
tested for internal consistency, retaining the indicators that had inter-item and item-total correlations
of between .35 and .85, a Cronbach coefficient of
approximately .95, and the normality of distribution
that is at the core of the definition of the construct.
The scale is unifactorial in structure and maintains a
test-retest stability of .68 to .80 under apparently constant conditions. To validate the tool, we compared
groups that differed in social and economical status
and urban density, school examinations and holidays,

VOL 49: SEPTEMBER SEPTEMBRE 2003

Canadian Family Physician Le Mdecin de famille canadien 1159

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Table 1. Psychological stress measure PSM-9


Check the number that best indicates the degree to which each statement has applied to you recently, that is, in the last 4 to 5 days.
DESCRIPTION OF MOOD

NOT AT ALL

NOT REALLY

VERY LITTLE

A BIT

SOMEWHAT

QUITE A BIT

VERY MUCH

EXTREMELY

I feel calm.
I feel rushed; I do not seem to have
enough time.
I have physical aches and pains: sore
back, headache, stiff neck,
stomachache.
I feel preoccupied, tormented, or
worried.
I feel confused; my thoughts are
muddled; I lack concentration; I cannot
focus.
I feel full of energy and keen.
I feel a great weight on my shoulders.
I have difficulty controlling my
reactions, emotions, moods, or
gestures.
I feel stressed.
Lemyre et Tessier, 1988, 2002.

and benign and malignant diagnostic biopsies.


Convergence validity was established with classic
depressive or anxiety scales; divergence validity was
established by distinct factorial scores on these measurements. Concomitant validity with immune competency was demonstrated in a double before-after
design of school stress and holidays, using salivary
immunoglobulin concentrations. The discriminatory
power of the PSM was also tested on a clinical sample of patients with schizophrenia and major depression. Finally, the predictive power of the PSM over an
8-month period, with respect to indicators of physical
health among child-care workers, was significant.
The PSMs responsiveness and normality of distribution give it statistical power in analysis, hence
its usefulness in research designs. For longitudinal
follow-up protocols with repeated measurements, two
parallel 25-item versions were developed using the
original long version, and each showed a Cronbach
coefficient of .92 and .93.
For general sur veys of health and well-being
in the workplace, an abridged 9-item version was
developed (Table 1) to meet a variety of research
needs and applications. The PSM-9 version is used
at Hydro-Qubec and Renault (France) as well as in
public service, hospitals, community services, and

1160 Canadian Family Physician Le Mdecin de famille canadien VOL 49:

private practice. Having been translated into English,


Japanese, Spanish, Portuguese, and Italian, it can be
used for international comparisons. It has the same
psychometric qualities of reliability, validity, and
internal consistency (.89) and maintains the same
heuristic value for statistics: normality of distribution
and responsiveness.
Psychological stress is an important factor in
health, and tools that are generally available are
inadequate for studying the normal population. We
believe, therefore, that the PSM is a critical measurement instrument for those conducting research in
family medicine.
Dr Lemyre is affiliated with the School of Psychology,
Faculty of Social Sciences, and with the Institute of
Population Health at the University of Ottawa in Ontario.
Dr Tessier is affiliated with the School of Psychology,
Faculty of Social Sciences, and with the CHUQ Research
Centre at the Pavillon St-Franois dAssise at Laval
University in Quebec.
Reference
1. Lemyre L, Tessier R, Fillion L. La Mesure du stress psychologique: manuel
dutilisation. Qubec, Que: Behaviora; 1990.

SEPTEMBER SEPTEMBRE 2003

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